Employment/Intern Application Form

Position Applying*

Chief of StaffPolicy AdvisorLegislative Aide (Internship)Communications Aide (Internship)Press SecretaryAdministrative Assistant
Name:*

First NameLast Name
Birth Date

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How were you referred to us?*

Walk-InEmployeeNewspaper AdFacebookTwitterOther (please specify)
Others:
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Job Skills & Training
Describe your skills:*
Degree/Training/Certifications:*
References

Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Notification and Authorization to Release Criminal Information for Employment Purposes
Notification

The position for which I am being considered requires me to consent to a criminal background check as a condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided during the past 7 years; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided.

Authorization

I hereby authorize Representative Jeramey Anderson and/or his designee to conduct the criminal background check described above. In connection with this, I also authorize the use of law enforcement agencies and/or private background check organizations to assist in collecting this information.
Other Names You Have Used in Past Seven Years:
Previous Address (most recent):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete. I understand that any falsification or omission of information may disqualify me for this position and/or may serve as grounds for the severance of my employment with Representative Jeramey D. Anderson. By signing below I hereby provide my authorization to Representative Jeramey D. Anderson and/or his designee to conduct a criminal background check. In addition to those rights, I understand that I have a right to appeal an adverse employment decision made by Reprsentative Jeramey D. Anderson based on my background check information within three business days of receipt of such notice and that a determination on my appeal will be made in seven working days of such appeal.
Initials*
Submit Application:
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am hired, I understand that I may be terminated at any time.

I agree to conform to the administration's rules and regulations, and I agree that my employment can be terminated, with or without cause, and without notice, at any time.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the administration.
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